Combined Traumatic Tricuspid Regurgitation and Acute Myocardial Infarction After Fist Blows to the Chest

A 15-year-old male patient with no previous medical history was brought to the emergency room after an assault. He was mentally confused, and his vital signs were as follows: blood pressure, 80/40 mm Hg; heart rate, 120 bpm; respiration rate, 22 breaths per minute; and body temperature, 36.5°C.The patient suffered multiple contusions all over his body with no evidence of fracture or bleeding. On auscultation, a subtle holosystolic murmur was heard at the left lower parasternal border. A chest x-ray demonstrated mild cardiomegaly, and an ECG showed sinus tachycardia with complete right bundle-branch block (Figure 1). Laboratory test results were as follows: serum creatinine phosphokinase, 5057 IU/L (normal range: 22–269 IU/L); creatinine phosphokinase-MB, 272.6 ng/mL (normal range: 0–7.2 ng/mL); troponin-I, >50 ng/mL (normal range: 0–0.3 ng/mL); serum myoglobin, >1200 ng/mL (normal range: 0–154 ng/mL); and urine myoglobin, >4000 ng/mL (normal range: 0–10 ng/mL). Transthoracic echocardiography revealed a moderate tricuspid regurgitation (TR) with a flail septal leaflet caused by chordae rupture (Figure 2 and Movie I in the online-only Data Supplement). However, …